Airway Management and Intubating without Drugs

@KingCountyMedic I read your response before you deleted it, it was good

I don't mean to take anything away from KCM1, from an outsiders perspective you guys have an awesome job for EMS and you've done great things in EMS research. You rewrote (or at least significantly refined) the playbook on resuscitation and your methods are used across the nation (including my department). Although for full disclosure, I've always felt it a bit disingenuous to make it appear that your Utstein survival rates are your overall survival rates.

I guess the point of my post about CPAP is twofold. First off, to reiterate what many of us are thinking which is that this really is a great tool and it's surprising that a department of your quality and reputation still hasn't implemented.. Secondly, it's a good reminder that even the best appearing jobs from the outside (who doesn't want to come in to work and do ONLY ALS??) still have their quirks which some would find quite frustrating..
 
VentMonkey said:
I’d be interested to know how this pans out for you and your program. It’s such a simple calculation, and I think it’d help keep things like resuscitation prior to induction and it’s ok to take a minute if it will save you several post-induction in the back of the providers minds.
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Air methods already did a study on this and we have implemented the focus on resuscitation with the use of PDP if needed. Using vasopressin or phenyl depending on type of pt. I forgot the actual numbers regarding peri-arrest with RSI but they found patients with <80mmhg and ETCO2 <25 was not good obviously. Also very strong on the focus of proper pre-oxygenation using different techniques.
 
TRSpeed said:
Air methods already did a study on this and we have implemented the focus on resuscitation with the use of PDP if needed. Using vasopressin or phenyl depending on type of pt. I forgot the actual numbers regarding peri-arrest with RSI but they found patients with <80mmhg and ETCO2 <25 was not good obviously. Also very strong on the focus of proper pre-oxygenation using different techniques.
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This is all correct. It was recently published. Right now we are trying to determine if Vaso for trauma and Neo for medical patients is the best option for PDP.

This is our RSI checklist that is utilized on all RSI patients. PDP are not specifically mentioned but are fit in during the prep/planning stage.
C6E7C723-A856-49C7-91A9-8BCE8B7CC1CF.jpeg
 
DesertMedic66 said:
This is all correct. It was recently published. Right now we are trying to determine if Vaso for trauma and Neo for medical patients is the best option for PDP.

This is our RSI checklist that is utilized on all RSI patients. PDP are not specifically mentioned but are fit in during the prep/planning stage.View attachment 4487
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Don’t be showing everyone our secrets -_- jk
 
TRSpeed said:
Don’t be showing everyone our secrets -_- jk
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Eric Bauer will give the secret away soon enough.

I actually mentioned to my base manager the other day that I think the HEAVEN criteria is much better than LEMONS but we will never switch since its an Air Methods thing.
 
GMCmedic said:
Eric Bauer will give the secret away soon enough.

I actually mentioned to my base manager the other day that I think the HEAVEN criteria is much better than LEMONS but we will never switch since its an Air Methods thing.
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HEAVEN was recently published into the new PHTLS course so it’s going to be widely taught now. HEAVEN is not used as a tool to determine if it’s going to be a difficult intubation but rather focuses on what device (VL vs DL) is possibly going to be the better one to use.
 
Another trend that came out of that retrospective study was that the vast majority of peri-intubation arrests were high shock index patients induced with Ketamine
 
A nice little updated piece on current recommendations for RSI meds and different subsets of patients. There isn't a whole lot of change I see, but figured worth a share.

UpToDate

www.uptodate.com www.uptodate.com
 
DesertMedic66 said:
HEAVEN was recently published into the new PHTLS course so it’s going to be widely taught now. HEAVEN is not used as a tool to determine if it’s going to be a difficult intubation but rather focuses on what device (VL vs DL) is possibly going to be the better one to use.
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This 2mg/kg bolus of Ketamine ought to bump their pressure right up...
 
Tigger said:
This 2mg/kg bolus of Ketamine ought to bump their pressure right up...
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Actually our medical directors sent out a memo not too long ago that we have not been seeing a rise in pressures with any of our ketamine dosages. Their pressures have either stayed the same or have decreased.
 
DesertMedic66 said:
Actually our medical directors sent out a memo not too long ago that we have not been seeing a rise in pressures with any of our ketamine dosages. Their pressures have either stayed the same or have decreased.
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Weve seen the same
 
I haven't seen pressures go up in critically ill patients with ketamine. I have seen it with procedural sedation in otherwise health patients, but that is certainly a different population.
 
I was being facetious. Unfortunately many people still think this, despite it being very apparent that it doesn't work that way.
 
Mercy Air (AMC) went to PDP with the last update of their Patient Care Guidelines (PCGs).

1-2mg/kg Ketamine is still the preferred induction agent in trauma or sepsis (hypotension).

In an adult with a SBP <90, phenylephrine is the preferred PDP in the NON-traumatic patient. 200mcg q 2 mins until SBP>90.
In a trauma patient, the PDP is Vasopressin 2 units q 2 minutes until SBP>90.

ETA: these are IV/IO doses.

Also, I do believe there is a contradictory study out there showing PDP have poor long term outcomes. I’ll have to do some searching for that one.
 
Here’s a great article with multiple studies and some take home tips for PDP applicability inhospital ED/ICU. However, it can be applied to EMS critical care.

One study showed nearly 30% of the patients had adverse reactions which included reflex bradycardia. However, others showed none. One BIG however, is that these are retrospective studies and while this article was published in 2019 it is not based on any RCTs.

Personally, I’m a fan of PDP, although 28-70% of patient still require additional vasopressor infusions.

Good stuff here.
 
PDPs I think are intended to be bridge therapies until an infusion is readied. To me, patients requiring them are going to be very sick and therefore likely to have poor outcomes, I wonder how the study controlled for that.
 
I hope AMC expands the PDP protocol to also be used as a bridge to infusion as opposed to strictly peri-intubation. The protocol is frequently being misused or liberally applied.

Also still frustrated not having pre-filled PDPs. Mixing PDPs kind of defeats the purpose and is not quick or accessible in an emergency. If you are having to mix a Vaso/Neo drip just to pull out the PDP then you mind as well just start an infusion.
 
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